RESE ARCH HIGHLIGHT
California’s Statewide Mental Health Prevention and
Early Intervention Initiatives Show Promising Early Results,
But Sustained Investment Is Needed
Key findings:
• California has launched a historic effort to improve its
residents’ mental health through prevention and early
intervention (PEI) initiatives.
• Statewide mental health programs have designed
resources and programs, reached large numbers of
Californians, and improved the knowledge, attitudes,
and intentions of those who were reached.
• Statewide PEI programming should be sustained to
enable observation of cumulative effects on longer-term
outcomes over the course of time.
• Ongoing measurement of the mental health of Californians
is critical for tracking needs, assessing longer-term impacts
of PEI investments, and targeting future programming.
T
he California Mental Health Services Authority
(CalMHSA)—a coalition of California counties—has
implemented an ambitious, first-of-its-kind set of statewide prevention and early intervention (PEI) initiatives to
help reduce mental health stigma and discrimination, prevent
suicide, and improve student mental health. Under the initiatives, program partners developed resources and programs
and implemented PEI activities as part of a greater strategic
plan aimed at improving mental health among residents. The
plan was carefully developed through a process that involved
diverse stakeholders (Clark et al., 2013). The programming
was funded by Proposition 63, the Mental Health Services
Act, and implementation began in 2011.
RAND’s evaluation of CalMHSA PEI initiatives to
date shows that program partners developed the capacities
to deliver numerous new PEI activities and that their efforts
have resulted in new infrastructure, staff expertise, resources,
collaborative relationships, training programs, and educational materials developed and tailored for diverse target
audiences. The statewide mental health PEI programming
has reached large numbers of Californians and improved
the knowledge, attitudes, and intentions of those who were
reached.
This has all been accomplished in a relatively short
time—four years to date—despite the many challenges
inherent in developing new program activities on a statewide
level. However, without sustained investment in programming, many of the gains will be lost. For example, the
impacts of social marketing campaigns can be short-lived
unless the campaigns are continued (Collins et al., 2012).
Fortunately, the costs for sustaining already-developed interventions are much lower than the costs of initially developing
them.
This brief reviews some of RAND’s key evaluation
findings regarding program implementation and short-term
outcomes and discusses why sustained investment in programming and evaluation is important.
California’s Statewide PEI Programs Have Reached
Many Californians, and the Results Are Promising
CalMHSA mental health PEI programs have used various
mechanisms to reach a large number of Californians. These
include the following:
Social marketing campaigns were associated with
reduced mental illness stigma and greater confidence to
intervene with those at risk for suicide. Social marketing
campaigns aim to use concepts from marketing to change
people’s knowledge, attitudes, and behavior. The “Each Mind
Matters” stigma reduction campaign has reached 1 in 4
California adults, and reach is growing (Burnam et al., 2014;
Collins et al., 2015). Since the campaign’s inception, the
stigma of mental illness has decreased in California: More
Californians say they are willing to socialize with, live next
door to, and work closely with people experiencing mental
illness, and they report that they are providing greater social
support to those with mental illness (Collins et al., 2015).
These changes are small but significant and are comparable
to those attained by campaigns in other countries.
–2–
The suicide prevention social marketing campaign
“Know the Signs” targets helpers of those at risk of suicide,
and this campaign is also reaching a large number of Californians and having a positive impact. Experts in suicide
prevention and social marketing campaigns have found that
the campaign is aligned with best practices and hold it in
high regard (Acosta and Ramchand, 2014). The campaign
has reached more than half of Californian adults (Ramchand
et al., 2015), and those exposed to the campaign report
greater increases in confidence to intervene with those at risk
for suicide than those who were not exposed to the campaign
(Ramchand et al., 2015).
Trainings improved knowledge, attitudes, and beliefs
about mental illness, and made participants feel more
prepared to help those in distress. CalMHSA-funded
trainings have also reached large numbers of people across
the state, and the individuals who attend these trainings are
benefiting from them, with participants experiencing small
but significant changes in knowledge, attitudes, and intentions. For instance, trainings of staff in California’s K–12
schools and of faculty, staff, and students in California’s
higher education systems were attended by large, racially and
ethnically diverse audiences. Attendees not only are satisfied with the trainings but also report improvements in their
confidence to refer and intervene with students who appeared
to be emotionally distressed (Osilla et al., 2015a; Osilla et al.,
2015b).
Several statewide programs have provided training that
aimed to reduce stigma and discrimination toward individuals with mental illness. For instance, trainings conducted by
Mental Health America of California and Disability Rights
California, although different in nature, both successfully
addressed a variety of stigma-related attitudes, beliefs, and
intentions among attendees, with the largest changes in
participants’ willingness to interact with people experiencing
mental illness (Cerully et al., 2015a). The National Alliance
on Mental Illness (NAMI) successfully implemented more
than 2,000 CalMHSA-funded trainings that reached over
18,000 individuals and had positive effects (Wong et al.,
forthcoming[a]; Wong et al., forthcoming[b]). NAMI’s
“Ending the Silence” training for high school students
resulted in immediate and substantial improvements in
students’ knowledge about mental health, as well as in
positive shifts in emotional responses and attitudes toward
people with mental health challenges. NAMI’s adult educational programs—In Our Own Voice (IOOV), Parents and
Teachers as Allies (PTasA), and Provider Education Program
(PEP)—also improved adults’ attitudes toward persons with
mental illness, particularly in their willingness to socialize
with, live next door to, and work closely with individuals
with mental illness.
CalMHSA-funded suicide prevention trainings also
appear to be a good investment. CalMHSA has funded a
cadre of Californians to become trainers in Applied Suicide
Intervention Skills Training (ASIST). RAND observed a few
training sessions and found that these new trainers demonstrated high fidelity to the prescribed training (Osilla et al.,
2014). Cost-benefit analyses of ASIST showed that just one
year of CalMHSA’s investment in creating this group of
ASIST trainers is projected to prevent at least 3,600 suicide
attempts and 140 deaths over the next 28 years. By averting these suicide attempts and deaths, the state government
will gain $50 for each $1 invested in ASIST through averted
Medi-Cal health care costs and increased state income tax
revenue (Ashwood et al., 2015a, 2015b).
Online resources reached many Californians, and
efforts to drive people to websites were key. CalMHSA
funded a number of websites and online resources intended
to reduce mental illness stigma that have been visited many
times—more than 650,000 visits in a year’s time and more
than 66,000 downloaded resources (Cerully et al., 2015b).
The majority of website visits—60 percent—originated from
within California. However, more than 80 percent of California visits originated from the three largest metro areas—
Los Angeles, Sacramento, and San Francisco—indicating
a continued need to reach less populous areas of the state.
Some program partners were more successful than others in
encouraging Californians to use their websites, indicating
that website sponsors need to invest in actively driving their
target audiences to the resources in order for them to be used
as designed. Thoughtful dissemination of online resources
appears to be at least as important as their initial development and can leverage earlier investments.
Collaborative partnerships influenced mental health–
related policies in California. CalMHSA supported
program partners’ efforts to develop collaborations to better
serve communities, and our evaluation found that some collaborative groups have been able to influence policy or create
and disseminate products with widespread impact across
institutions and communities. For instance, a student mental
health policy workgroup influenced state teacher credentialing standards: The workgroup recommended enhancing
collaborative partnerships to link students to appropriate services, as well as requirements that K–12 educators be trained
to facilitate students and their families’ access to mental
health services, and these standards were adopted by the state
(Woodbridge et al., 2014).
–3–
Efforts to Reduce Stigma and Discrimination and
Improve Student Mental Health Should Continue
Although CalMHSA’s stigma reduction efforts are working,
there is still much work to do in this area. Among people
who themselves have mental illness, 9 out of 10 reported
having been discriminated against in the past year because
of their mental health problem; consistent with their perceptions of stigma and discrimination, more than 2 in 3 with
mental illness would definitely or probably hide a mental
health problem from coworkers or classmates, and more than
1 in 3 would hide it from family or friends (Wong et al.,
2015). These high levels of perceived stigma and discrimination may help explain why almost half of California adults
with serious psychological distress did not seek treatment in
the past year (Wong et al., 2015).
One area for improvement is reaching subpopulations
in California in which stigma toward those with mental
illness is still high—for example, among Asian Americans,
who make up 14 percent of California’s population (Collins et al., 2014). There is also a need for targeted efforts to
reach California’s college campuses, where almost 1 in 5
higher education students reported probable psychological
distress and high rates of impairment due to mental health
problems (Sontag-Padilla et al., 2014). The need for intervention appears to be particularly high at California Community Colleges (CCCs): Despite having comparable levels of
mental health issues, CCC students reported greater levels of
mental health–related impairment yet lower rates of using or
receiving referrals for counseling or mental health services,
compared with students in the University of California and
California State University systems. RAND’s evaluation
found that most higher education staff and faculty are unsure
of the warning signs of mental health distress and do not
have the skills to discuss mental health issues with students,
and many remain uncertain about where to refer students
with mental health needs. Most had not yet participated in
trainings intended to foster such knowledge and skills. The
largest barrier to participation was lack of knowledge that
the trainings were offered (Sontag-Padilla et al., 2014), which
underscores the importance of continued outreach to provide
trainings shown to be effective (Osilla et al., 2015a).
Monitoring Progress
These results are available because of CalMHSA’s commitment to independent evaluation, including statewide monitoring of key mental health indicators. From a public health
perspective, ongoing measurement of the mental health of
Californians is critical for tracking needs, assessing longerterm impacts of PEI investments, and targeting future mental
health PEI programming. CalMHSA’s investments so far have
provided a baseline (and relatively short-term follow-ups), and
continued investment would make it possible to understand
how key mental health indicators change over time.
Continued monitoring is especially important in California because the various components of the statewide mental
health PEI efforts are designed to support and enhance one
another to create greater change, and this reciprocal influence is likely to be evident only at a later time. Improving the
mental health of an entire state will not happen overnight.
Statewide monitoring efforts can make it possible to track
progress and direct efforts where they are most needed.
Conclusion
CalMHSA’s efforts to implement statewide mental health
PEI programs to reduce mental health stigma and discrimination, prevent suicide, and improve student mental health
have resulted in substantial progress over the past four years.
RAND’s evaluation provides evidence that PEI initiatives
successfully developed resources and programs; reached
large numbers of Californians; and improved the knowledge, attitudes, and intentions of those who were reached.
However, the researchers were able to evaluate only relatively
short-term, proximal outcomes, and most of the effects
found so far were small in size—which is to be expected,
given the length of time the programs have been operating.
As a comparison, successful stigma campaigns in England
and Australia have been under way for more than a decade
(TNS BMRB, 2015; Wyllie and Lauder, 2012). Statewide
PEI programming and evaluation efforts should be sustained
to enable observation of cumulative effects on longer-term
outcomes. Without strategic and continued investment in
statewide PEI programming, many of the gains associated
with the larger initial investment are at risk of being lost.
–4–
This brief highlights key findings from the following publications:
Acosta, Joie D., and Rajeev Ramchand, “Know the Signs” Suicide
Prevention Media Campaign Is Aligned with Best Practices and Highly
Regarded by Experts, Santa Monica, Calif.: RAND Corporation,
RR-818-CMHSA, 2014, www.rand.org/t/RR818.
Ashwood, J. Scott, Brian Briscombe, Rajeev Ramchand, Elizabeth
May, and M. Audrey Burnam, Analysis of the Benefits and Costs
of CalMHSA’s Investment in Applied Suicide Intervention Skills
Training (ASIST), Santa Monica, Calif.: RAND Corporation,
RR-1115-CMHSA, 2015a, www.rand.org/t/RR1115.
Ashwood, J. Scott, Brian Briscombe, Rajeev Ramchand, Elizabeth
May, and M. Audrey Burnam, “Should California Continue to
Invest in Applied Suicide Intervention Skills Training (ASIST)?
ASIST Could Save Lives and Wages and Reduce Medical Costs,”
Santa Monica, Calif.: RAND Corporation, RB-9849-CMHSA,
2015b, www.rand.org/t/RB9849.
Burnam, M. Audrey, Sandra H. Berry, Jennifer L. Cerully, and
Nicole K. Eberhart, “What Has the CalMHSA Statewide Mental
Health Prevention and Early Intervention Program Done So Far?
Key Results from the Baseline RAND General Population Survey,”
Santa Monica, Calif.: RAND Corporation, RB-9771-CMHSA,
2014, www.rand.org/t/RB9771.
Cerully, Jennifer L., Rebecca L. Collins, Eunice C. Wong, Elizabeth Roth, Joyce Marks, and Jennifer Yu, Effects of Stigma and
Discrimination Reduction Trainings Conducted Under the California
Mental Health Services Authority: An Evaluation of Disability Rights
California and Mental Health America of California Trainings, Santa
Monica, Calif.: RAND Corporation, RR-1073-CMHSA, 2015a,
www.rand.org/t/RR1073.
Cerully, Jennifer L., Courtney Ann Kase, Rebecca L. Collins,
Eunice C. Wong, and Jennifer Yu, CalMHSA Stigma and Discrimination Reduction Online Resources: Highlights from an Evaluation
of Web Analytic Data, Santa Monica, Calif.: RAND Corporation,
RR-1237-CMHSA, 2015b, www.rand.org/t/RR1237.
Osilla, Karen Chan, Dionne Barnes-Proby, Mary Lou Gilbert, and
Rajeev Ramchand, A Case Study Evaluating the Fidelity of Suicide
Prevention Workshops in California, Santa Monica, Calif.: RAND
Corporation, RR-755-CMHSA, 2014, www.rand.org/t/RR755.
Osilla, Karen Chan, Asha Goldweber, Rachana Seelam, Courtney
Ann Kase, Elizabeth Roth, and Bradley D. Stein, Mental Health
Trainings in California’s K–12 System Are Associated with Increased
Confidence and Likelihood to Intervene with and Refer Students,
Santa Monica, Calif.: RAND Corporation, RR-953-CMHSA,
2015a, www.rand.org/t/RR953.
Osilla, Karen Chan, Michelle W. Woodbridge, Rachana Seelam,
Courtney Ann Kase, Elizabeth Roth, and Bradley D. Stein, Mental
Health Trainings in California’s Higher Education System Are Associated with Increased Confidence and Likelihood to Intervene with and
Refer Students, Santa Monica, Calif.: RAND Corporation, RR-954CMHSA, 2015b, www.rand.org/t/RR954.
Ramchand, Rajeev, Elizabeth Roth, Joie D. Acosta, and Nicole
K. Eberhart, Adults Newly Exposed to “Know the Signs” Campaign
Report Greater Gains in Confidence to Intervene with Those Who
Might Be at Risk for Suicide Than Those Unexposed to the Campaign,
Santa Monica, Calif.: RAND Corporation, RR-1134-CMHSA,
2015, www.rand.org/t/RR1134.
Sontag-Padilla, Lisa, Elizabeth Roth, Michelle W. Woodbridge,
Courtney Ann Kase, Karen Chan Osilla, Elizabeth D’Amico, Lisa
H. Jaycox, and Bradley D. Stein, CalMHSA Student Mental Health
Campus-Wide Survey: 2013 Summary Report, Santa Monica, Calif.:
RAND Corporation, RR-685-CMHSA, 2014, www.rand.org/t/
RR685.
Wong, Eunice C., Rebecca L. Collins, Jennifer L. Cerully,
Elizabeth Roth, and Joyce Marks, Stigma, Discrimination, and
Well-Being Among California Adults Experiencing Mental Health
Challenges, Santa Monica, Calif.: RAND Corporation, RR-1074CMHSA, 2015, www.rand.org/t/RR1074.
Collins, Rebecca L., Eunice C. Wong, Jennifer L. Cerully, and
Elizabeth Roth, Racial and Ethnic Differences in Mental Illness
Stigma in California, Santa Monica, Calif.: RAND Corporation,
RR-684-CMHSA, 2014, www.rand.org/t/RR684.
Wong, Eunice C., Rebecca L. Collins, Jennifer L. Cerully, Elizabeth Roth, Joyce Marks, and Jennifer Yu, Effects of Stigma and
Discrimination Reduction Trainings Conducted Under the California
Mental Health Services Authority: An Evaluation of NAMI’s Ending
the Silence, Santa Monica, Calif.: RAND Corporation, RR-1240CMHSA, forthcoming(a).
Collins, Rebecca L., Eunice C. Wong, Jennifer L. Cerully, Dana
Schultz, and Nicole K. Eberhart, Interventions to Reduce Mental
Health Stigma and Discrimination: A Literature Review to Guide
Evaluation of California’s Mental Health Prevention and Early
Intervention Initiative, Santa Monica, Calif.: RAND Corporation,
TR-1318-CMHSA, 2012, www.rand.org/t/TR1318.
Wong, Eunice C., Rebecca L. Collins, Jennifer L. Cerully, Elizabeth Roth, Joyce Marks, and Jennifer Yu, Effects of Stigma and
Discrimination Reduction Trainings Conducted Under the California
Mental Health Services Authority: An Evaluation of the National Alliance on Mental Illness Adult Programs, Santa Monica, Calif.: RAND
Corporation, RR-1247-CMHSA, forthcoming(b).
Collins, Rebecca L., Eunice C. Wong, Elizabeth Roth, Jennifer
L. Cerully, and Joyce Marks, Changes in Mental Illness Stigma
in California During the Statewide Stigma and Discrimination
Reduction Initiative, Santa Monica, Calif.: RAND Corporation,
RR-1139-CMHSA, 2015, www.rand.org/t/RR1139.
Woodbridge, Michelle W., Asha Goldweber, Jennifer Yu, Shari
Golan, and Bradley D. Stein, California K–12 Schools and Communities Collaborate to Support Student Mental Health, Santa Monica,
Calif.: RAND Corporation, RR-688-CMHSA, 2014, www.rand.
org/t/RR688.
–5–
Other citations:
Clark, Wayne, Stephanie N. Welch, Sandra H. Berry, Ann M.
Collentine, Rebecca Collins, Dorthy Lebron, and Amy L. Shearer,
“California’s Historic Effort to Reduce the Stigma of Mental Illness: The Mental Health Services Act,” American Journal of Public
Health, Vol. 103, No. 5, May 2013, pp. 786–794 (EP-51403, www.
rand.org/t/EP51403).
TNS BMRB, Attitudes to Mental Illness: 2014 Research Report:
Prepared for Time to Change, April 2015.
Wyllie, Allan, and James Lauder, Impacts of National Media Campaign to Counter Stigma and Discrimination Associated with Mental
Illness: Survey 12: Response to Fifth Phase of Campaign, Auckland,
New Zealand: Phoenix Research, June 2012.
–6–
RAND Health
This research was conducted in RAND Health, a division of the RAND Corporation. A profile of RAND
Health, abstracts of its publications, and ordering information can be found at http://www.rand.org/health.
CalMHSA
The California Mental Health Services Authority (CalMHSA) is an organization of county governments
working to improve mental health outcomes for individuals, families, and communities. Prevention and early
intervention programs implemented by CalMHSA are funded by counties through the voter-approved Mental
Health Services Act (Prop. 63). Prop. 63 provides the funding and framework needed to expand mental health
services to previously underserved populations and all of California’s diverse communities.
About RAND
The RAND Corporation, a not-for-profit public policy research organization based in Santa Monica, California,
provided an independent evaluation of the CalMHSA-funded statewide programs, working with program
partners, the CalMHSA Statewide Evaluation Experts team, CalMHSA staff, and many California residents
who contributed their experiences and opinions.
The RAND Corporation is a nonprofit institution that helps improve policy and decisionmaking through research and analysis. RAND focuses
on the issues that matter most, such as health, education, national security, international affairs, law and business, the environment, and more.
As a nonpartisan organization, RAND operates independent of political and commercial pressures. We serve the public interest by helping
lawmakers reach informed decisions on the nation’s pressing challenges. RAND’s publications do not necessarily reflect the opinions of its
research clients and sponsors. R® is a registered trademark. © RAND 2015
Limited Print and Electronic Distribution Rights: This document and trademark(s) contained herein are protected by law. This representation of RAND
intellectual property is provided for noncommercial use only. Unauthorized posting of this publication online is prohibited. Permission is given to
duplicate this document for personal use only, as long as it is unaltered and complete. Permission is required from RAND to reproduce, or reuse in
another form, any of our research documents for commercial use. For information on reprint and linking permissions, please visit www.rand.org/
pubs/permissions.html.
www.rand.org
RB-9863-CMHSA (2015)
CHILDREN AND FAMILIES
EDUCATION AND THE ARTS
The RAND Corporation is a nonprofit institution that helps improve policy and
decisionmaking through research and analysis.
ENERGY AND ENVIRONMENT
HEALTH AND HEALTH CARE
INFRASTRUCTURE AND
TRANSPORTATION
This electronic document was made available from www.rand.org as a public service
of the RAND Corporation.
INTERNATIONAL AFFAIRS
LAW AND BUSINESS
NATIONAL SECURITY
POPULATION AND AGING
PUBLIC SAFETY
SCIENCE AND TECHNOLOGY
TERRORISM AND
HOMELAND SECURITY
Support RAND
Browse Reports & Bookstore
Make a charitable contribution
For More Information
Visit RAND at www.rand.org
Explore the RAND Corporation
View document details
Research Brief
This product is part of the RAND Corporation research brief series. RAND research briefs present
policy-oriented summaries of individual published, peer-reviewed documents or of a body of published
work.
Limited Electronic Distribution Rights
This document and trademark(s) contained herein are protected by law as indicated in a notice appearing
later in this work. This electronic representation of RAND intellectual property is provided for noncommercial use only. Unauthorized posting of RAND electronic documents to a non-RAND website
is prohibited. RAND electronic documents are protected under copyright law. Permission is required
from RAND to reproduce, or reuse in another form, any of our research documents for commercial use.
For information on reprint and linking permissions, please see RAND Permissions.